University of California, Los Angeles
SHORT APPLICATION TO USE HUMAN PLURIPOTENT STEM CELLS IN RESEARCH
(PLEASE NOTE: All research intended to create or use covered stem cells requires prospective UCLA Embryonic Stem
Cell Research Oversight (ESCRO) Committee review and approval.)
PROJECT TITLE:
PRINCIPAL
Name
INVESTIGATOR:
Department
Degree(s)
Campus Mailing Address
CO-INVESTIGATOR
Name
or FACULTY SPONSOR:
Department
PRIMARY CONTACT
PERSON:
Degree(s)
Campus Mailing Address
Name
APPLICATION STATUS:
Campus Phone No.
New
Amendment
Renewal
University Title
Campus Phone No.
Campus Mail Code
e-mail Address
University Title
Campus Phone No.
Campus Mail Code
e-mail Address
e-mail Address
Previous ESCRO Committee number, if applicable:
SECTION I: ASSURANCES
INVESTIGATOR'S ASSURANCE
I certify that the information provided in this application is complete and correct.
I understand that as Principal Investigator, I have ultimate responsibility for the conduct of the study, the ethical performance
of the project, and strict adherence to any stipulations imposed by the ESCRO Committee.
I agree to comply with all UCLA policies and procedures, as well as with all applicable Federal, State, and local laws
regarding hESC research, including, but not limited to, the following:
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performing the project by qualified personnel according to the approved protocol,
implementing no changes in the approved protocol without prior ESCRO Committee approval,
promptly reporting significant or untoward adverse effects to the ESCRO Committee in writing within 5 working
days of occurrence,
if I will be unavailable to direct this research personally, as when on sabbatical leave or vacation, I will arrange for an
ESCRO Committee approved co-investigator to assume direct responsibility in my absence,
ANY DISTRIBUTION OF CELLS OR DERIVATIVES TO INDIVIDUALS NOT NAMED IN THIS PROTOCOL
REQUIRES PROSPECTIVE REVIEW AND APPROVAL OF BANKING AND DISTRIBUTION PROCEDURES BY
THIS COMMITTEE.
____________________________________________________________________
Principal Investigator
Date
FACULTY SPONSOR’S ASSURANCE
By my signature as sponsor on this research application, I certify that the student is knowledgeable about the regulations and
policies governing research with hESCs/pluripotent stem cells and has sufficient training and experience to conduct this
particular study in accord with the approved protocol. In addition,
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I agree to meet with the investigator on a regular basis to monitor study progress.
Should problems arise during the course of the study, I agree to be available, personally, to supervise the investigator in
solving them.
I assure that the investigator will promptly report significant or untoward adverse effects to the ESCRO Committee in
writing within 5 working days of occurrence.
If I will be unavailable to direct this research personally, as when on sabbatical leave or vacation, I will arrange for an
ESCRO Committee approved co-investigator to assume direct responsibility in my absence.
____________________________________________________________________
Faculty Sponsor * (if PI is a student or a fellow)
Date
 The faculty sponsor must be a member of the UCLA faculty. The faculty member is considered the responsible party for
legal and ethical performance of the project.
ESCRO short app hPSC 120328.doc
Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
Please provide the following information about all co-Investigators:
1. [Name, degree]
[Title]
[Campus mailing address]
[Campus telephone]
[Campus email]
2.
3.
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
SECTION II – FUNDING
THIS SECTION MUST BE COMPLETED
1. Check all of the appropriate boxes for funding sources of this research, include pending funding source(s):
Extramural*
UCLA Academic Senate
Department
Gift
Other: ______________
None
* P.I. of Contract or Grant:
Funding Source:
Contract or Grant No.:
Contract or Grant Title:
2. If using an IDENTICAL protocol for more than one extramural funding proposal, list all funding sources
below. Attach an additional sheet if more space is needed.
a. P.I. of Contract or Grant:
Funding Source:
Contract or Grant No.:
Contract or Grant Title:
b. P.I. of Contract or Grant:
Funding Source:
Contract or Grant No.:
Contract or Grant Title:
3. ESCRO: Please provide one (1) copy of each grant or contract to the ESCRO.
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
THIS SECTION MUST BE COMPLETED
For purposes of this application, cell line means a human pluripotent stem cell (hPSC).
SECTION III – hPSC DATA
A. Provenance of hPSC.
1. Please provide the requested information regarding the source of the cell lines.
[see http://stemcells.nih.gov/research/registry/ for information]
2.
If you are using somatic cells for reprogramming, please provide information relevant to the somatic cells
3.
If you will be obtaining the cells from the UCLA Broad Stem Cell Research Center Core Bank, please indicate
as much in the Vendor column.
Vendor
NIH Registry & Vendor Number
EX: WiCell
1.
2.
3.
4.
NIH-0043, WiCell: H1
MTA Number
06-W008
Number of lines
2
B. Please outline the expertise and training of investigators and research staff working with stem cells.
(Note: Include the Principal Investigator’s information first. Please also attach curriculum vitae in NIH Biosketch
form for each listed personnel. CIRM regulations and NAS guidelines require documentation of sufficient hESC
training or an explanation of training to be provided.)

Last name, First name, degree
Title
Training in Stem Cell Science
(outline the experience, expertise or training in
derivation or culture of stem cells)
1.
2.
3.
C. Location of the research (Note: Research may take place in multiple locations. Please indicate all locations)
Building Name
EX: Factor
Room number(s)
9-664
1.
2.
D. Please attach other required compliance committee approvals (e.g., Medical Radiation Safety Committee,
Institutional Biosafety Committee, etc) or forward as they become available.
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
1.
SECTION IV: PROTOCOL
OBJECTIVES
1.1:
Please clearly and concisely state the objectives as they correspond to the hypothesis to be tested in the
research.
1.2:
2.
SCIENTIFIC BACKGROUND AND RATIONALE
2.1:
Please provide sufficient background information to justify the research rationale, including, an outline of
why the proposed scientific design requires the use of hESCs or other covered cells1 (referred to in this
document as “stem cells”) rather than alternative methodologies. Please include an outline of the previous
and supporting research conducted and the peer reviewed scientific journal articles or other supporting data.
2.2:
3.
Please outline how the study design will answer the scientific questions posed in the objectives.
Are there valid alternatives to using stem cells in the proposed research?
___Yes ____ No
2.2.1:
If no, please explain why.
2.2.2:
If yes, please outline the alternatives and provide a justification for the use of stem cells in your
research.
Information about the cells:
Yes
No
a. Is the cell line intended for basic research?
b.
Were the cells derived in clinical grade facilities?
c.
If yes to 1(b), could the cells be used in humans? If no, please explain why.
d.
Does the research introduce hPSCs into non-human primate blastocysts?
e.
Does the research introduce any hPSCs into human blastocysts?
4.
PROPOSED EXPERIMENTS
Please outline the proposed experiments for the research.
5.
Microbiology (COMPLETE SECTION 5 ONLY IF YOU ARE RECEIVING CELLS FROM ANOTHER
INVESTIGATOR, BANK, OR REPOSITORY.)
5.1. Please outline the tests performed on the donor tissue of origin. (Please include the source of the
data and the technique(s) used.)
5.2. Tests performed on the cells (Please indicate the passage level or frequency at which tests on
sterility, Mycoplasma and viral tests are carried out.)
The CIRM defines “covered cells” as “…culture-derived, human pluripotent stem cell population that is capable of: 1)
sustained propagation in culture; and (2) self-renewal to produce daughter cells with equivalent developmental potential.
This definition includes both embryonic and non-embryonic human stem cell lines regardless of the tissue of origin.
‘Pluripotent’ means capable of differentiation into mesoderm, ectoderm, and endoderm [CA H&S Code 100020(c)].”
Therefore, ESCRO review is required for research with human embryonic stem cells and populations, regardless of their
origin, capable of differentiation into multiple tissue types. Adult precursors that differentiate into cells of a single tissue type
do not meet all three CIRM criteria and would not be subject to ESCRO review.
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
5.3. Describe the culture conditions used, including supplier and catalogue number(s).
5.3.1
5.3.2
5.3.3
5.3.4
5.3.5
5.3.6
5.3.7
Growth medium
Basal medium
Supplements
Growth factors/cytokines
Type of serum used
Incubation temperature
Describe the atmospheric conditions
5.4. Passage Procedures
5.4.1. _____ Number of passages
Yes
No
5.4.2.
Will/were enzymes used? If yes, please indicate the type of enzyme
used (including the supplier and catalogue number).
5.4.3
Will/were other methods used? If yes, please provide details.
5.4.4.
Please specify the usual split ratio (i.e., surface of area of culture pre: post subculture).
5.4.5
Please indicate the seeding density (cells/cm2 or colonies/cm2).
5.4.6
Please indicate the typical frequency of passage and viability of harvested cells. Please
attach a copy of the passage protocol.
6.4.5
5.4.6
5.4.7
Will/were feeder cells used? If yes, please state the type of cells
(including the mouse strain) used. (Please attach a copy of the protocol used to prepare
the feeder cells).
Please clarify whether the stem cells will be/were preserved and provide the typical
percentage of viability obtained on thawing. Please attach a copy of the protocol.
Please explain the methods used to induce differentiation. Please attach details of the
procedure.
6.
STORAGE AND PROCESSING OF Stem Cells
6.1:
Describe the process for characterizing the cells
6.2:
Describe the process for expanding, maintaining, and storing the cells
6.3:
Outline the system for quality assurance and control of the cells
6.4:
If you wish to maintain the cells after the completion of the research, please explain how and where the cells
will be maintained.
6.4.1. If the cells will be banked and distributed to other investigators, please provide the number and PI
name of the existing Bank.
6.4.2. If you will create a new Bank for the storage and distribution of the cells to other investigators,
please complete the Banking Stem Cells protocol application.
7.
SERIAL MEASUREMENTS
Guidelines:List the study parameters/milestones and the timeline for completion. Chart format is helpful, in
addition to a narrative.
8.
CRITERIA FOR ASSESSMENT
Guidelines: Indicate how you will assess outcomes
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
9.
ANIMAL RESEARCH (Please Note: prospective Chancellor’s Animal Research Committee (ARC) approval is
required when using covered animal subjects in stem cell research http://www.oprs.ucla.edu/animal/ .)
Will the research include work with animals? ____Yes ____No
If yes, please complete the following:
9.1:
Please list the animals and include the quantity of each animal necessary to accomplish the research goals.
Animal
EX: scid-hu mice
1.
2.
3.
9.2.
Number of animals
5
Please outline the animal experiments describing how the experiments will contribute to the goals of the
research.
9.3 Implantation into non-human fetuses:
9.3.1
____Yes ____ No: Will hESC derivatives, hESC cells, or other pluripotent cells be introduced
into non-human fetuses and allowed to develop into adult chimeras? If so, please explain the
extent of human contribution to the resulting animal. Consideration of any major functional
contributions to the brain should be explained.
9.3.2
Please outline the consequences of the human contributions to the resulting chimeras.
9.3.3
____ Yes ____ No: Will this protocol include the introduction of hESCs or other pluripotent
cells into non-human primate blastocysts? 2
9.3.4
____ Yes ____ No: Will this protocol include the introduction of non-human ESCs or other
pluripotent cells3 into human blastocysts?
9.4 Please provide a timeline for euthanizing animals beginning with the introduction of hESC or other pluripotent
cells to the animals.
9.4.1
Please also explain whether the period after introduction of stem cells into the animals and to the
point of euthanizing the animals is sufficient to allow the hESC or other pluripotent cells to make
major functional contributions to the brain.
9.5 Will animals be allowed to breed: ____ Yes ____ No
9.5.1
If no, please complete Sections 7.6 and 7.7
9.5.2
If yes, please complete Section 7.8
2
The CIRM regulations require and the National Academies of Science Guidelines for Human Embryonic Stem Cell
Research recommend that research involving the introduction of hPSCs into non-human primate blastocysts or non-human
ESCs into human blastocysts not be approved at this time. CIRM Regulations, Scientific and Medical Accountability
Standards: http://www.cirm.ca.gov/reg/default.asp, & National Research Council – Institute of Medicine of the National
Academies, 2005.
3
The CIRM defines “covered cells” as “…culture-derived, human pluripotent stem cell population that is capable of: 1)
sustained propagation in culture; and (2) self-renewal to produce daughter cells with equivalent developmental potential.
This definition includes both embryonic and non-embryonic human stem cell lines regardless of the tissue of origin.
‘Pluripotent’ means capable of differentiation into mesoderm, ectoderm, and endoderm [CA H&S Code 100020(c)].”
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
9.6 Please explain how you will ensure that the animals do not breed. [Veterinarian Advice: The appropriate
methods and safeguards, consistent with proper veterinary and ARC policies, for keeping mice (as an example)
of reproductive age from breeding. Mice are typically weaned between 21 and 28 days after birth. At this time,
they are segregated by gender (males in one cage, females in another). Delayed weaning or inaccurate sexing
of the weanlings may lead to unintended mating among littermates and pregnancies, which could generate
offspring arising from hESC-carrying chimeras.]
9.7 Also, please outline the safeguards necessary to keep co-mingling of hESC chimeric animals with the general
animal population. [Veterinarian Advice (using mice as an example): Chimeras should be housed in properly
identified/labeled cages with express instructions not to house these chimeras with other mice (or other mice of
the opposite sex). This would have to be clearly explained to both research and husbandry staff – only one
mouse cage must be open at any given time in the laminar-flow hood during routine cage changing to prevent
any co-mingling.]
9.8 If the animals will be allowed to breed, please explain and provide a scientific justification for allowing the
animals to breed.4
10. EXTERNAL COLLABORATIONS
Guidelines: Describe any arrangements with or procedures conducted by non-UCLA investigators.
1. [Name of collaborating institution]
[Name of collaborator, degree]
[Title]
[Mailing address]
[Telephone]
[Email]
[Description of arrangements or procedures conducted by the listed individual]
4
The NAS Guidelines indicate, No animal into which hES cells have been introduced at any stage of development should be
allowed to breed.
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Short Application to use HUMAN PLURIPOTENT Stem Cells in Research
SECTION V: GUIDELINES
A. Short Form
UCLA policy requires that all research with human pluripotent stem cells undergo scientific
review. Strictly laboratory research that uses existing hPSC lines, the creation of iPSC from
known commercially available somatic cells (ex: Corriell, ATCC), or use of hPSC on the NIH
Registry require only may use this short form. In order for the hPSC lines to be eligible for
Federal funding they must meet the following criteria:
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The cell line must have been one of the NIH identified lines either in existence prior to
August 9, 2001 http://stemcells.nih.gov/research/registry/eligibilityCriteria.asp or on the new NIH
Registry http://stemcells.nih.gov/research/registry/,
The stem cells must have been derived from an embryo that was created for reproductive
purposes,
The embryo was no longer needed for such purposes,
Informed consent was obtained from donors,
No financial inducements were provided for donation of the embryo, or
The covered hPSC did not require the destruction of an embryo in its creation (e.g.,
induced pluripotent stem cell (iPSC) and have already been approved by the ESCRO).
Since stem cell lines in the NIH Stem Cell Registry must meet the above criteria in order to
qualify for the registry or were previously approved by the ESCRO, you are not required to
provide information about donors, such as informed consent, recruitment, financial inducements,
or the original derivation process.
B. Review Requirements
CA Law and National Academies of Science hESC Guidelines
California law and the National Academy of Science (NAS) hESC research guidelines require a
scientific evaluation of the proposal and a thorough accounting of the cells. The NAS
“subscribe[d] to the consensus of many bioethics bodies throughout the world that a system of
oversight of [hESC] research should be in place.” 5
Chancellor’s Animal Research Committee (ARC)
hESC research that includes animal subjects may be required to undergo prospective ARC
review.6 Please contact the ARC at arc@oprs.ucla.edu or x49565, if you have questions about
animal research.
Institutional Biosafety Committee (IBC) and Other Compliance Committees
hESC research that falls within the purview of the IBC and/or other relevant compliance
committees must also receive prospective approval from those committees.
5
Committee on Guidelines for Human Embryonic Stem Cell Research (NAS-IOM Report), Guidelines for Human Embryonic
Stem Cell Resarch, National Research Council – Institute of Medicine of the National Academies, 2005.
6
www.oprs.ucla.edu
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